Numerous articles have been published on fat injection; therefore, we will only describe the points that make FAMI™ so specific. After analysis of aging changes or other defects, an individualized plan of the injection pattern to be used is formulated, selecting subperiosteal (bone), intramuscular, and fat pad locations to be addressed and noted on a form.

Subperiosteal injections are usually 0.5–1.0 mL in one pass, intramuscular 1.0–2.0 mL with exceptions (procerus 0.5 mL, mentalis 3.0 mL, platysma up to 5.0 mL) in two passes, and fat pads 1.0–5.0 cc in three to five passes. A circulator records the graft volumes as they are administered.

Diet-resistant donor areas are chosen with the patient in standing position, most frequently using the inner part of the knees or the love handles region that are genetically present in men and women.

Injection with Klein’s solution begins within the deep supra-aponeurotica plane followed by the subcutaneous space, making the central fat deposit relatively free of anesthetic solution. (According to Klein, 0.1 % lidocaine with 1:1,000,000 epinephrine into the subcutaneous tissues of a concentration of 35 mg/kg is safe.) The disposable harvesting cannula is connected to a 10 mL Luer-Lok syringe. A negative pressure in the syringe body is created by pulling the syringe plunger two 1 mL graduations. The harvesting FAMI™ cannula of the set is made with a round-tipped, two-hole stainless steel tube making the samples bloodless. The fatty connective tissue is gently aspirated with a movement going back and forth to reproduce a multiple biopsy piercing more than a conventional liposuction.

To prevent any leakage and air mixture during the spinning process, an aluminum cap seals the 10 cc syringes. After removal of the syringe from the centrifuge, we can observe (Fig. 28.2), on top, a layer of less density, yellow in color, mainly composed of the oil of destroyed fat cells; this layer can measure up to 5 cc in program 1 (bone program). In the bottom, the pink layer is mainly constituted of blood, lidocaine, and saline with debris. The middle layer is composed of an accumulation of tissues: free fat cells, fat cells within a stromal vascular fraction (SVF) that contain the mesenchymal stem cells, and a lower white crescent of pure collagen.

Sticking to the opening of the syringe, an accumulation of platelets is present in bloody samples. This fraction is always removed when present; it contains PGF or platelet growth factors which are added to the SVF.

Different programs are used according to the facial tissue to be augmented: bone, muscle, or fat pad (Table 28.2). Lipoaspirates centrifuged at higher G force (13,680) tend to be more liquid and are injectable subperiosteally. Intermediate G force (5,000) is used for muscle injection. Lower G force (1,200) processing is done when larger-volume corrections with lobulated fat aggregations are desired, such as in the fat pads.

Complete trigeminal sensory nerve block is administered using Naropin 0.5 % (ropivacaine 5 mg/100 ml—AstraZeneca) along with cervical sensory branches if neck bands are to be addressed. Lorazepam 0.5 mg PO or similar sedative and clonidine 0.1–0.2 mg are useful adjuncts preoperatively.

Access ports (Fig. 28.3) are made with a tapered tip awl, which minimizes any dermal bleeding and avoids suture. From any of them, one can enter the origin or the insertion of each muscle with fewer traumas. These locations are free of vessels and nerves. Rarely bleeding coming from severed venous capillaries is stopped by few minute compressions.

The processed lipoaspirates are transferred into 1 and 3 mL Luer-Lok syringes for injection with the appropriate cannula. Acquired technical skill and a detailed knowledge of the anatomy are necessary to successfully place the grafts (Table 28.3).

How does the surgeon know that the cannula is inside the muscle envelope? This is a very recurrent question asked by non-anatomist surgeons. Under the facial skin, there is no dead space. If the cannula fails to enter the superficial musculoaponeurotic system (SMAS) envelope of each muscle, it is very difficult to inject due to the soft tissue resistance. Correct intramuscular placement is associated with no resistance at all; as the plunger is depressed, it becomes very easy to inject with each withdrawal. 1 or 2 passes are used for each muscle. The real quantity is evaluated with little experience. We feel a little resistance when the muscle is full. The systematization of the injections, from periosteum to skin, more superficial anatomical plane after deeper anatomical plane, is one more characteristic of the FAMI™ procedure.

Benzoin solution is applied after the procedure, and the patient is asked not to wash his or her face for 3 days. In the immediate postoperative period, the patient leaves the facility with no dressing and little postoperative discomfort. The bruising will appear on the first postoperative day around the approach sites and in the lower lid.